Mental health among commando, airborne and other UK infantry personnel
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Occupational Medicine 2010;60:552–559 Advance Access publication on 5 September 2010 doi:10.1093/occmed/kqq129 Mental health among commando, airborne and other UK infantry personnel J. Sundin1, N. Jones1, N. Greenberg1, R. J. Rona2, M. Hotopf2, S. Wessely2 and N. T. Fear1 1 Academic Centre for Defence Mental Health, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London SE5 9RJ, UK, 2King’s Centre for Military Health Research, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London SE5 9RJ, UK. Correspondence to: J. Sundin, Academic Centre for Defence Mental Health, King’s College London, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. Tel: 144 (0)20 7848 5344; fax: +44 (0)20 7848 5397; e-mail: Josefin.email@example.com Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 ................................................................................................................................................................................... Background Despite having high levels of combat exposure, commando and airborne forces may be at less risk of mental ill-health than other troops. ................................................................................................................................................................................... Aims To examine differences in mental health outcomes and occupational risk factors between Royal Ma- rines Commandos (RMCs), paratroopers (PARAs) and other army infantry (INF). ................................................................................................................................................................................... Methods Three groups of personnel (275 RMCs, 202 PARAs and 572 INF) were generated from a UK military cohort study of personnel serving at the time of the 2003 Iraq war. Participants completed a question- naire about their mental health and experiences on deployment. Differences in mental health out- comes between the groups were examined with logistic regression and negative binomial regression analyses. ................................................................................................................................................................................... Results Both RMCs and PARAs were less likely to have multiple physical symptoms or to be fatigued, and RMCs also had lower levels of general mental health problems and lower scores on the Post-traumatic Checklist than INF personnel. Differences were not explained by the level of unit cohesion. ................................................................................................................................................................................... Conclusions The effect of warfare on troops’ well-being is not universal across occupational groups. A possible explanation for this difference is that the high level of preparedness in RMCs and PARAs may lessen the psychological impact of war-zone deployment experiences. ................................................................................................................................................................................... Key words Airborne forces; commando forces; marines; PTSD; UK. ................................................................................................................................................................................... Introduction forces. Like RMCs, PARAs are highly trained to enable them to operate independently for long periods and under Most military forces utilize commando and airborne in- harsh conditions . fantry troops who are subject to a more rigorous selection Since commando and airborne forces are likely to be process and undergo more arduous training compared exposed to traumatic situations more frequently, it fol- with other infantry troops; in the UK armed forces, these lows that they should be at increased risk of ill-health. include Royal Marines Commandos (RMCs) and air- However, research does not support this view. Recent borne forces such as paratroopers (PARAs) [1–2]. These UK studies have shown that the prevalence of post- forces often undertake more hazardous military duties, traumatic stress disorder (PTSD) tends to be low in com- such as deploying to newly established and uncertain the- mando and airborne forces, such as RMCs and PARAs atres of operations. The RMCs are the amphibious infan- [3–4], but the lack of a non-commando or airborne forces try of the UK armed forces and are a core component of control group in the study by Hacker Hughes et al.  the UK rapid deployment force. Their role requires them limits their conclusions. Similar findings of resilience in to be ready to deploy at short notice and they are trained marines compared with army and navy personnel have to fight in any terrain; they are the UK armed forces’ spe- been reported in US studies [5–7]. cialists in cold weather and mountain warfare . The The role of unit cohesion is of growing interest for PARAs are the airborne infantry element of the British studies of psychological health in military personnel. Sev- Army; their role is to operate with minimal, or no support, eral studies and meta-analyses have examined and dem- potentially behind enemy lines and against superior onstrated a positive relation between unit cohesion and The Author 2010. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: firstname.lastname@example.org
J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 553 performance . There is also support for a relationship two airborne support units of artillery and engineers) and between improved well-being and readiness with higher other INF were identified through information on parent levels of unit cohesion, and unit cohesion may serve as unit. N.J. (a serving member of the Defence Medical a resilience factor for PTSD and combat stress reactions Services) advised on the generation of these groups. Only [3,9,10]. Recent research has also shown that there is an regular male personnel were studied due to the small association between unit cohesion and excessive alcohol numbers of females and reserve personnel in the RMCs use, with heavy drinking being associated with moderate and PARAs groups. to high levels of comradeship in theatre . There is also Participants provided information on socio-demographic some evidence to suggest higher levels of individual and and military characteristics, deployment experiences and unit morale among US marines compared to US Army current health. Childhood adversity was assessed as soldiers . a composite score of 16 questions on childhood experien- This study examines differences in mental health out- ces . Information on deployment experiences in- comes and occupational risk factors between RMCs, cluded the area of deployment, time spent in a forward PARAs and other army infantry (INF). We hypothesized area and potentially adverse experiences on deployment that RMCs and PARAs would show fewer adverse mental (coming under small arms fire, coming under mortar Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 health outcomes and higher levels of unit cohesion as or artillery attack and seeing personnel wounded or compared to other INF. killed). Two questions assessed appraisals of deployment experiences: thinking one might be killed and whether work in theatre matched trade and experiences (perceived Methods preparedness). Unit cohesion was conceptualized as a construct based Data were utilized from a study of UK military personnel on seven variables that assessed comradeship, leadership who were in service during March 2003 and who partic- and whether personnel felt well informed during deploy- ipated in the first wave of a prospective cohort study ment (Table 1). Four of the items were taken from a sec- [12,13]. Invited participants were from a random sample tion asking personnel about their perceptions of their stratified by service, enlistment type (regular or reserve deployment and were measured on a five-point scale from personnel) and deployment status. Reserve personnel ‘strongly disagree’ to ‘strongly agree’. The other three were over-sampled by a ratio of 2:1. Data were collected items were part of a question on what aspects of their de- through postal surveys and visits to military bases. The ployment personnel felt were most and least rewarding. cohort comprised of 4722 personnel who had deployed For each item, personnel had the option of ticking most on Op TELIC 1 (the military code name for the first rewarding, least rewarding or neither. All seven items phase of the 2003 Iraq war) and 5550 personnel who were were recoded on a binary scale, with the ‘neither’ category not deployed on TELIC 1 (referred to as Era). Personnel coded as missing. in the Era group may have deployed on later phases of The scale reliability was acceptable (Cronbach’s a 5 TELIC or on other major deployments. 0.77). The unit cohesion construct was generated The response rate was 61%. Analysis of non-responders through principal component analysis (PCA) of a tet- showed that age, rank, gender, ethnic group and enlist- rachoric correlation matrix, which is appropriate for bi- ment type differed between responders and non- nary data . The PCA resulted in a two-factor responders, but there were no differences in fitness to solution with one general factor that explained 61.0% deploy . Weighting for non-response had little effect of the total variance. The factor loadings ranged between on the relative risks, which indicates that bias was small. 0.47 and 0.86 and the standardized factor loadings were The study received approval from the Ministry of used to generate the unit cohesion construct. Defence (MOD) research ethics committee and the PTSD was measured with the 17-item National Cen- King’s College Hospital local research ethics committee. tre for PTSD Checklist (PCL-C) , with cases defined Analyses were made on a subsample of respondents as those scoring $50. Due to insufficient numbers of who had deployed on a major operation since 2000, PTSD cases in the RMC and PARA groups, the PCL- and who were RMCs (n 5 275), PARAs (n 5 202) or C score was used as outcome measure in the multivariate members of other INF regiments (n 5 572). The sample analyses. The score was recoded from 17–85 to a range was identified through information on Service branch from 0–68 for the purpose of the multiple variable anal- (i.e. Royal Navy, Royal Marines, British Army and Royal yses. Alcohol use was measured with the alcohol use dis- Air Force) and parent unit, obtained from the cohort orders identification test , with cases defined as those study questionnaire and from the Defence Analytical scoring $16. Fatigue was measured with the Chalder fa- Services Agency. RMCs were identified by their service tigue scale , with cases defined as those scoring $4. numbers and included personnel who served in a Royal Symptoms of common mental disorder were measured Marines infantry or support unit. PARAs (defined as per- with the General Health Questionnaire 12 (GHQ-12) sonnel who belonged to three airborne combat units and  with cases defined as those scoring $4. Physical
554 OCCUPATIONAL MEDICINE Table 1. Variables and response scale of the seven items included in mental health outcome analyses were repeated on this the unit cohesion construct subsample. Variables Response scale How much do you agree or disagree with Results the following statements: I felt a sense of comradeship (or 1 Strongly disagree The groups differed on several socio-demographic closeness) between myself and other 2 Disagree aspects (Table 2). Compared to the INF, PARAs were people in my unit. 3 Neither younger and had deployed for less time in the past 3 years. I could have gone to most people in my 4 Agree RMCs, compared with the INF, had higher educational unit if I had a personal problem. 5 Strongly agree My seniors were interested in what I did attainment, were less likely to hold a rank of junior non- or thought. commissioned officer and had lower levels of childhood I felt well informed about what was adversity. Compared with RMCs, PARAs were younger, going on. had deployed for less time in the past 3 years and reported What if any were the three most rewarding more childhood adversity. Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 and three least rewarding aspects of your PARAs and RMCs were more likely to have service on Op TELIC: deployed on any phase of TELIC compared with the Quality of leadership of senior chain of 1 Most rewarding INF (Table 3). Time spent in a forward area differed be- command was among the three most/ 2 Least rewarding least rewarding aspects of service. tween the groups, with PARAs and RMCs more likely to Quality of leadership of immediate spend up to a month, while the INF tended to spend no commanders was among the three time, or more than a month, in a forward area. Preva- most/least rewarding aspects lence of combat exposures was high in all three groups. of service. RMCs were more likely to have come under mortar or Teamwork/Comradeship was among the three most/least rewarding aspects artillery fire and to have seen personnel wounded or of service. killed compared to the INF. Personnel in the INF were more likely to have come under small arms fire compared with the PARAs. There was no difference in levels of unit cohesion be- symptoms were assessed with a checklist of 53 common tween PARAs and the INF. In contrast, RMCs had higher symptoms, with cases defined as individuals endorsing levels of unit cohesion compared with the other two $18 symptoms . groups. Socio-demographic characteristics, pre-deployment There were differences in length of time between leav- and combat experiences were compared between the ing theatre and completing the questionnaire. While three groups. Proportions were calculated and statistical PARAs and INF personnel averaged .500 days between significance was assessed with Pearson’s x2 statistic. leaving theatre and completing the questionnaire, RMCs Associations between group membership and mental averaged .700 days. However, time from leaving theatre health outcomes were assessed with odds ratios (OR), cal- to completing the questionnaire was not associated with culated with binary logistic regression, and incidence-rate any of the mental health outcomes for the RMCs. ratios (IRR), calculated with negative-binomial regres- RMCs had lower rates of all negative mental health sion . We adjusted for variables that were related outcomes except alcohol use, which was comparable to to both group membership and the mental health out- the rate for the INF (Table 4). Following adjustment, comes. For all models, the socio-demographic and pre- PARAs had lower rates of fatigue and physical symptoms deployment variables were fitted first followed by the than the INF. Low levels of unit cohesion were predictive deployment and post-deployment risk factors. The cut- of all mental health outcomes but did not account for dif- off for inclusion in the model was set at P values #0.10. ferences between the groups. There were no differences Differences in theatre of deployment were adjusted for between the RMCs and PARAs for these mental health in all models. Goodness-of-fit was assessed with the outcomes (data not shown). Hosmer–Lemeshow test  and fit was adequate for There was a significant interaction between childhood all models. adversity and group membership on the GHQ score (INF We examined stress reactivity with three interaction versus PARAs: x2(3) 5 10.26, P , 0.05), with PARAs effects for group membership and combat exposure being less reactive to high levels of childhood adversity. and also with two background factors (level of education The proportion of cases reporting PTSD symptoms and childhood adversity). Differences in theatre of de- was similar for the INF and the PARAs. RMCs had sig- ployment were adjusted for in all models. nificantly fewer cases of PTSD compared with the INF, A sensitivity analysis was carried out for personnel who P , 0.05 (Fisher’s exact test), but not compared with had deployed on a TELIC operation (n 5 874) and all the PARAs (not significant).
J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 555 Table 2. Socio-demographic characteristics of the INF, PARAs and RMCs Socio-demographic and INF (n 5 572)a PARAs (n 5 202)a RMCs (n 5 275)a INF versus INF versus PARAs versus pre-deployment variables PARAs RMCs RMCs n (%) n (%) n (%) P value P value P value Age (years) 29.9 (29.3–30.4)b 28.4 (27.5–29.2)b 30.4 (29.6–31.3)b ,0.05 NS ,0.001 Educational statusc No qualifications 94 (17) 19 (10) 18 (7) NS ,0.001 NS GCSE or equivalent 289 (54) 107 (55) 129 (48) A-levels or equivalent 100 (19) 46 (24) 87 (32) Degree 56 (10) 22 (11) 37 (14) Rank Other rank 140 (25) 66 (34) 92 (34) NS ,0.05 NS Junior non- 227 (40) 72 (37) 85 (31) commissioned officer Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 Senior non- 132 (23) 37 (19) 60 (22) commissioned officer Officer 65 (12) 22 (11) 34 (13) Had prior deployment 450 (79) 147 (73) 211 (78) NS NS NS experience Time deployed for in past 3 years #6 months 148 (27) 67 (34) 65 (24) ,0.05 NS ,0.001 7–12 months 249 (45) 92 (34) 108 (40) .12 months 161 (29) 38 (19) 95 (36) Medically downgraded 45 (8) 9 (5) 20 (7) NS NS NS Number of childhood adversity factors 0/1 97 (17) 40 (20) 57 (21) NS ,0.001 ,0.05 2/3 146 (26) 55 (27) 97 (35) 4/5 122 (21) 35 (17) 67 (24) $6 207 (36) 72 (36) 54 (20) Numbers (n), percentages (%), means (M) and 95% CIs are displayed together with P values for t-tests and x2 statistics. NS 5 not significant. a Some categories do not add up to denominators because of missing data. b Mean and 95% CI and corresponding t-test. c General Certificate of Secondary Education (GCSEs) are examinations usually taken at age 16. A-levels are usually taken at age 18 and are required for entry to university. The difference in PCL-C score between RMCs and Discussion the INF held after adjusting for socio-demographics, pre-deployment factors and experiences on deployment Combat exposures were common in all three groups, but (Table 5). In contrast, after adjusting for covariates, the the prevalence of mental ill-health was generally low. Our lower rates of PCL-C scores in PARAs compared with hypotheses of lower rates of psychological distress and the INF were removed. After adjusting for covariates, higher unit cohesion among RMCs and PARAs were only RMCs also had lower PCL-C scores compared with partially supported. Consistent with previous research, the PARAs. RMCs reported lower levels of mental ill-health and There were interactions between seeing personnel had higher levels of unit cohesion compared to the wounded or killed and group membership on PCL-C INF [5,6]. This was not the case for PARAs, who were score, both for the comparison between PARAs and comparable to the INF on levels of unit cohesion, general INF (IRR 0.43, 95% CI 0.25–0.74) and for the PARAs mental health problems and PCL-C scores. PARAs also and RMCs comparison (IRR 2.66, 95% CI 1.30–5.44). had higher PCL-C scores than the RMCs. In contrast, PARAs were less stress-reactive to seeing personnel both RMCs and PARAs were less likely to be fatigued wounded or killed compared with the INF and RMCs. or experience multiple physical symptoms compared with Replication of the analyses on only TELIC-deployed the INF. participants showed that there was no effect of TELIC Interactions between group membership and seeing deployment on the comparisons between the RMCs or personnel wounded or killed on PCL-C score indicated the PARAs with the INF or between the RMCs and that PARAs were less stress-reactive to witnessing trauma the PARAs (data available from the authors). to others than both the INF and RMCs. High levels of
556 OCCUPATIONAL MEDICINE Table 3. Deployment experiences of the INF, PARAs and RMCs Deployment INF (n 5 572)a PARAs (n 5 202)a RMCs (n 5 275)a INF versus INF versus PARAs versus experiences variables PARAs RMCs RMCs n (%) n (%) n (%) P value P value P value Any TELIC 434 (76) 190 (94) 250 (91) ,0.001 ,0.001 NS deployment Time spent in a forward area Not at all 153 (28) 35 (18) 55 (20) ,0.05 ,0.001 NS Up to 1 month 155 (28) 77 (40) 129 (48) .1 month 248 (45) 81 (42) 86 (32) Came under small 322 (56) 89 (44) 146 (53) ,0.05 NS ,0.05 arms fire Came under mortar or 320 (56) 125 (62) 181 (66) NS ,0.05 NS Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 artillery fire Saw personnel 366 (65) 133 (66) 195 (71) NS ,0.05 NS wounded or killed Thought might be 383 (68) 126 (63) 174 (64) NS NS NS killed Work in theatre was 67 (15) 30 (16) 31 (12) NS NS NS generally outside experience/ability Unit cohesion (general 0.11 (0.03–0.20)b 0.01 (20.12, 0.15)b 0.25 (0.15–0.36)b NS ,0.05c ,0.05c factor) Time (days) between 532.5 (490.7–574.3)b 515.3 (478.7–551.9)b 729.4 (693.7–765.1)b NSc ,0.001c ,0.001c leaving theatre and completing questionnaire Numbers (n), percentages (%), means (M) and 95% CIs are displayed together with P values for t-tests and x2 statistics. NS 5 not significant. a Some categories do not add up to denominators because of missing data. b Mean and 95% CI and corresponding t-test. c t-test adjusted for unequal variances. childhood adversity also had a smaller effect on PARAs There is some evidence of low rates of PTSD in para- compared to the INF for symptoms of common mental dis- troopers  but the lack of a control group in that study order. However, PARAs were equally reactive to INF and limits the conclusions that can be drawn. The present RMCs regarding coming under small arms fire, coming un- study showed that PARAs had similar rates of symptoms der mortar or artillery fire and thinking they might be killed. of PTSD compared with the INF. These results fit with previous research that has com- The RMCs had fewer pre-deployment risk factors pared mental health outcomes between US marines and compared with the INF, with higher levels of education other troops. Studies have shown that combat-deployed and lower rates of childhood adversity. Previous studies marines had lower rates of psychiatric disorders com- have shown that high levels of childhood adversity pared to both non-deployed marines and navy personnel increase the risk of developing PTSD symptoms  and that marines report fewer mental health, family [14,23,24] and other mental health problems, such as de- and alcohol problems compared to army soldiers . pression and anxiety, in military populations . A US However, in the present study, alcohol problems were study of marines who had deployed to Iraq or Afghanistan comparable between the three groups. showed that marines who had higher levels of education, In contrast, a recent report of psychiatric morbidity measured as some college or a college degree, were at among the UK armed forces  showed that RMCs lower risk of screening positive for PTSD . had lower rates of any mental illness compared with The lower rates of mental ill-health in RMCs may also the other services, but the rates of PTSD were higher be a result of stigma. Research on stigma in the military among RMCs. However, these analyses were not adjusted has shown that it is more prevalent among individuals for covariates, and young age, female gender and deploy- who experience mental health problems . Concerns ments to Iraq or Afghanistan were also shown to be pre- regarding disclosure of psychiatric difficulties include be- dictors of PTSD and mental illness. ing perceived as weak and not being trusted by peers .
J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 557 Table 4. Unadjusted prevalence and logistic regression models comparing the PARAs and RMCs with other Army infantry (INF) on adverse health outcomes Cases, n (%) Unadjusted OR (95% CI) Adjusted OR (95% CI) N GHQ INF 132 (24) PARAs 36 (18) 0.73 (0.48–1.09) 0.81 (0.51–1.27)a 728 RMCs 34 (13) 0.46 (0.31–0.70) 0.58 (0.36–0.93)b 659 Fatigue INF 207 (37) PARAs 48 (25) 0.55 (0.38–0.80) 0.51 (0.34–0.78)c 721 RMCs 66 (24) 0.55 (0.40–0.76) 0.62 (0.43–0.89)d 811 Alcohol use disorders identification test INF 147 (26) PARAs 59 (30) 1.24 (0.87–1.78) 1.31 (0.85–2.02)e 630 RMCs 72 (26) 1.02 (0.73–1.41) 1.38 (0.95–2.02)f 826 Physical symptoms INF 92 (16) PARAs 16 (8) 0.45 (0.26–0.78) 0.40 (0.22–0.72)g 727 RMCs 19 (7) 0.39 (0.23–0.65) 0.36 (0.20–0.64)h 798 Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010 Number of cases (n), percentages (%), OR, 95% CIs are displayed together with numbers for the adjusted models (N). a Adjusted for age, rank, childhood adversity, theatre of deployment, coming under small arms fire and unit cohesion. b Adjusted for age, rank, childhood adversity, theatre of deployment, perception of work in theatre and unit cohesion. c Adjusted for rank, childhood adversity, theatre of deployment, thought might be killed and unit cohesion. d Adjusted for childhood adversity, theatre of deployment and unit cohesion. e Adjusted for age, childhood adversity, time deployed for in past 3 years, theatre of deployment, unit cohesion and time between leaving theatre and completing the questionnaire. f Adjusted for age, rank, childhood adversity and theatre of deployment. g Adjusted for rank, time deployed for in past 3 years, theatre of deployment, saw personnel wounded or killed and unit cohesion. h Adjusted for rank, childhood adversity, time deployed for in past 3 years, theatre of deployment, saw personnel wounded or killed and unit cohesion. Table 5. Negative binomial regression models of PCL-C scores in the UK MOD and that all personal information would the paratroopers (PARAs) and RMCs compared with other INF and be kept completely confidential. comparing the PARAs and RMCs Previous research has also suggested that the lower lev- els of PTSD symptom severity in RMCs is likely to be due PCL-C Cases, n (%) Unadjusted IRR Adjusted IRR N to higher levels of group cohesion, fitness and general mo- tivation . While RMCs had higher levels of unit cohe- INF 36 (6) sion, there was no difference between PARAs and the PARAs 12 (6) 0.75 (0.58–0.96) 0.91 (0.70–1.18)a 622 INF. This may explain why there were no differences RMCs 7 (3) 0.54 (0.43–0.67) 0.64 (0.52–0.79)b 800 PARAs 12 (6) in general mental health problems or PCL scores between RMCs 7 (3) 0.72 (0.52–1.00) 0.69 (0.49–0.98)c 456 PARAs and the INF. This study was based on data from a representative co- Number of cases (n), percentages (%), IRR, and 95% CIs are displayed together hort with a good response rate (61%) and we have shown with numbers for the final models (N). that response was not linked to health outcome [12,29], a Adjusted for rank, childhood adversity, theatre of deployment, coming under which suggests that response bias was unlikely. The study small arms fire, thought might be killed, unit cohesion and time between leaving was limited by the data collected in the larger cohort study theatre and completing the questionnaire. and therefore differences in the selection and training be- b Adjusted for rank, childhood adversity, theatre of deployment, coming under tween the groups could not be assessed. Future research small arms fire, saw personnel wounded or killed and unit cohesion. c can expand on this study by examining these factors. The Adjusted for childhood adversity, time deployed for in past 3 years, theatre of de- ployment, time spent in a forward area, saw personnel wounded or killed and unit cross-sectional nature of this study means that caution cohesion. should be exercised on the interpretation of the findings. All health outcomes were assessed with screening meas- ures and represent probable mental illness, except for Fear of a harmful effect on one’s career may lead to fewer PTSD that was measured as PCL-C score. disclosures of poor health in RMC and PARA personnel, A sensitivity analysis was carried out on only TELIC- who by the nature of their training and culture are more deployed personnel, and the results support that the dif- likely to favour resilience than regular troops. However, ferences in health outcomes between the RMCs and during recruitment for the study, all participants were in- PARAs compared to the INF were not due to the theatre formed that the study was conducted independently of of deployment.
558 OCCUPATIONAL MEDICINE We consider that our findings show that the effect of orary Civilian Consultant Advisor in Psychiatry to the British warfare on troops’ well-being is not universal across oc- Army and a Trustee of Combat Stress, a UK charity that pro- cupational groups. Both PARAs and RMCs had fewer vides services and support for veterans with mental health prob- physical symptoms and were less fatigued compared with lems. All the other authors declare that they have no conflict of interests. the INF, and RMCs were also less likely to have general mental health problems and had lower PCL-C scores. This effect appears to be independent of combat exposure and socio-demographic differences. A possible explanation References for this difference is that the high level of preparedness in 1. Allsopp AJ, Shariff A. 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